Audit supports move towards primary health providers - Leading COVID-19 community management

An audit of the management of COVID-19 cases at the Papakura Marae Health Centre during late 2021, co-authored by Professor Matire Harwood and research colleagues at the Medical Research Institute of New Zealand, has today been published in the New Zealand Medical Journal.

‘An audit of a marae-based health centre management of COVID-19 community cases in South Auckland’ outlines the ways in which the Papakura Marae Health Centre became the default provider of medical and welfare care for COVID-19 cases isolating in a Tāmaki Makaurau community during October and November 2021, in essence taking over the role of the Ministry of Health’s system in place at the time.

In October 2021, the New Zealand government announced that COVID-19 cases in the community would no longer be exclusively managed in Managed Isolation and Quarantine (MIQ) facilities. With a significant growth in cases in Tāmaki Makaurau, the isolation model moved towards Community Supported Isolation and Quarantine (CIQ) where those diagnosed with COVID-19 could expect regular contact via a remote check-in service run by Whakarongorau Aotearoa, contracted by the Ministry of Health.
Whakarongorau Aotearoa also manage the national COVID-19 helpline, vaccination bookings, and other telehealth services.

However, difficulties facing Whakarongorau Aotearoa and Ministry of Health were soon apparent, with reports of whānau isolating in homes that do not meet basic critera for safe isolation, and a failure to consistently perform timely check-ins and reviews. These delays in assessment and support, for both the clinical and general welfare needs of COVID-19 patients, resulted in primary health professionals, such as GP’s and Nurses, stepping-in to make house calls and offer basic needs, especially in the most at-risk communities.

In response to these reports and their own experience, the Papakura Marae Health Centre undertook an audit of their management of COVID-19 positive cases, using information documented in primary care records between 14 October and 18 November 2021.
The aim of the audit was to determine how the Papakura Marae Health Centre might improve both the clinical care and welfare of their patients, with the goal of ultimately improving health outcomes and avoiding preventable deaths.

With clinical leadership from doctors, Dr Karim Alipour-Almachavan, Dr Matire Harwood and Dr Jason Tuhoe, the Papakura Marae Health Centre is a primary health provider in South Auckland that serves a community of 3,200+, of whom 95 percent identify as Māori or Pacific Peoples. Its COVID-19 programme is led by nurse Nicole Waters, Practice Manager Barbara Betham, and CE Tony Kake.

The characteristics of the thirty-seven patients included in the audit highlighted their high risk in developing COVID-19 and the importance of delivering timely, comprehensive, and consistent high-quality medical and welfare care. Almost all patients were Māori or Pacific peoples, many living in areas of high socioeconomic deprivation. There were on-average six people per household with three positive COVID-19 cases per household. 15% of those eligible for vaccination had received two vaccine doses.

The audit showed that the level and quality of medical care provided by the Papakura Marae Health Centre through their clinical and support teams was of an extremely high standard. In addition to medical care, it was noted that the Papakura Marae Health Centre also provided extensive welfare support, in accordance with their holistic approach to healthcare. This included delivery of kai packages, medication, and hygiene packs to support their community members and whānau.

Professor Richard Beasley, Director of the Medical Research Institute of New Zealand says “It is evident from this audit that the Papakura Marae Health Centre essentially undertook the role of the Ministry of Health’s system. Furthermore, the level, quality, and continuity of medical care provided by the Papakura Marae Health Centre was clearly better than that which could ever be achieved by a system based on remote monitoring by non-medical personnel, guided by decision support tools."

Dr Matire Harwood, General Practitioner at Papakura Marae Health Centre and Senior Clinical Research Fellow at the Medical Research Institute of New Zealand says, “As a GP with a deep commitment to my community, there was no question of stepping in and supporting our whānau, especially when systems they anticipate would support them, did not. Primary care professionals across Aotearoa are able to best support their people, and I would strongly encourage the Ministry to immediately forge ways in which these practitioners could be adequately resourced to take responsibility of the management of patients with COVID-19 in the community.”

“An independent review panel stated that two of the deaths of COVID-19 cases in home isolation in Tāmaki Makaurau were potentially preventable. It's clear that more could have been done and needs to be done for our most vulnerable communities.” says Dr Harwood. “This audit publication is timely given there is now community spread of the highly transmissible Omicron variant. We have a clear and very real opportunity here for our health service systems to be stronger if there’s formal collaboration with local providers to best serve all New Zealanders through community focus.”

“By sharing details of the Papakura Marae Health Centre’s mahi through this audit, it is hoped that the Ministry of Health will continue to consider alternative collective models that deliver best care for COVID-19 patients in their communities.” says Professor Beasley.

“This audit shows the extraordinary capability and strong community focus of Māori Health providers such as Papakura Marae Health Centre.” says Professor Beasley. “It also gives an insight as to what might be further achieved with increased resourcing through the future Māori Health Authority.”

KEY POINTS AT A GLANCE

1. An audit of the management of thirty-seven COVID-19 cases by the Papakura Marae Health Centre in South Auckland between 14 October 2021 and 18 November 2021, has shown that the Papakura Marae Health Centre became the default provider of medical care and welfare for COVID-19 Community Supported Isolation and Quarantine (CIQ) cases, taking over the role of the Ministry of Health’s current system.

2. With reports of whānau isolating in unsafe homes and Whakarongorau Aotearoa and Ministry of Health failing to conduct timely check-ins, South Auckland primary care professionals and their support teams stepped in to monitor and care for community members.

3. The aim of the audit was to identify issues with the management of COVID-19 cases attending the Papakura Marae Health Centre, in order to put systems in place that might improve clinical and welfare care and subsequently avoid potentially preventable deaths.

4. Specific audit objectives were to ensure that COVID-19 cases in the community were appropriately reviewed by the Papakura Marae Health Centre; to ensure there was documented evidence of the clinical characteristics of COVID-19 cases; and to ensure there was documented evidence that the welfare needs of patients were ascertained.

5. The audit showed that the level and quality of medical care provided by primary care professionals was of an extremely high standard.

6. These audit findings offer the Ministry of Health a timely opportunity to review the current system and develop alternative collaborative models that give responsibility and resources to local primary health providers to lead the medical and welfare care for COVID-19 patients in their communities.

BACKGROUND AUDIT DETAIL

https://journal.nzma.org.nz/journal-articles/an-audit-of-a-marae-based-health-centre-management-of-covid-19-community-cases-in-south-auckland-open-access

Thirty-seven patients were included in this audit. Nineteen cases (51.3%) were enrolled patients at the practice while the remaining were casual patients. Forty-six percent of cases were aged 20 years or younger with three-quarter of cases isolating at home.

62.2% were women. 73.0% of the participants were Māori, 18.9% were Pacific Peoples and 3% were European New Zealanders. 18.9% work full-time, 2.7% work part-time, 43.2% were students and 29.7% were unemployed.

37.8% of patients came from a Decile 10 area, the most deprived socioeconomic demographic in Aotearoa New Zealand. 13.5% came from Decile 9; 5.4% from Decile 8; 8.1% from Decile 7; 24.3% from Decile 6; 2.7% from Decile 5; 5.4% from Decile 4 and 3.7% from Decile 3.

The mean number of persons per household was 5.8 with 3.3 positive cases in each household. Four out of the 26 cases who were eligible for vaccination were fully vaccinated at the point of diagnosis.

Of the COVID-19 cases attending the Papakura Marae Health Centre, 57% were first notified of their positive result by the clinic. There was documented evidence in the GP records that Whakarongorau Aotearoa contacted 48.6% of cases for clinical review when in home isolation.

In the majority of patients, all three standards were met by the Papakura Marae Health Centre processes. Twenty-nine out of 37 cases (78.4%) had a GP clinical review within two calendar days of Papakura Marae Health Centre being notified of the positive result. All cases had clear documentation of their clinical characteristics and were asked about their welfare needs.

Home visits were carried out by GPs on at least one occasion in 25 cases (67.6%). Oxygen saturation was measured at all initial home visits made by the GP.

In addition to providing medical care, Papakura Marae Health Centre is a Māori health care provider whose services are underpinned by ‘Te Whare Tapa Whā’. The provision of holistic healthcare involving the whole whānau was evidenced by the practice providing kai packs to 31 cases (83.8%), delivering medication to 14 cases (37.8%), and providing hygiene packs to the 13 cases (35.1%) that opted for it.